88-133 - Laserfiche WebLink

Home Browse Search

I r- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ��pp� � �_ Job Address City Lot Size 2 a4A,.&A. - PM P Owner's Name ddress Phone"YO -6' IH Contractor/ rAddressl ,/yy _ License No.` ct 5 Phone! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Ji Ji DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well-Casing t ❑ Domestic/Private ❑ Gravel,Pack ❑ Tracy_.,, -Type of Casing '- Specifications ! ('I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done L-1Typeof Pump H.P1. ` .3 € State Work Done 1 j Well Destruction ❑ Well Diameter Sealing Material (top 50') I I Depth; or terial (Below 50') t �' '` ! A TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIAD ITION I.I DESTRUCTION (No septic system permitted'if public sewer is available within 200 feet.) Installation will serve: Residence""'�'""'CUrff ercial'=Othirr-- -t Number of living units: 3 Number of bedrooms------(7 Character of soil to a depth of.3 feet: f�% a a Water labia depth i a SEPTIC TANK ❑ Type/Mfg- K- Capacity -Q_o...__ No. Compartments PKG. TREATMENT PLT. ❑ ' .. ��` Method of Disposal r M Distance to nearest:%" `Well,< ,Foundation � Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 412 r FILTER BED ❑ Distance to nearest: Well 4 Foundation Property Line + SEEPAGE PITS 1-1` Oepth. J Size t , Number ° + f SUMPS ❑ Distan a to neares : WellFoundation /v Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and . rules and regulations-of the San Joaquin Local Health District. } Nome owner or licensed agent's signature.cettifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not r empioy any person in such manner as to become subject 4:o workman's compensation laws of California." Contractor's hiring or sub contracting signature{ E certifies the-foljo'wing: "I certify that in the performance of_the work for which this permit.is issued,i shall employ persons subject to workman's compensa-# F rtion laws of California." ?he applican ust call for Al requir d inspections. Complete drawing on reverse side.' ? t Signed X )Title: Date: F DEPARTiVIENT USE ONLY Application Accepted by4d� Date �, Area' 0 Pit or Grout Inspection by Date -Final-Inspection by Date Li? r t Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369 621 ❑ Manteca 823-7104 U Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE t INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'NO. j a EH 13-24(REV,t%H 51 EH 14-2e �/